The Health Policy and Systems Data & Analysis Center (DAC), based at the University of the Western Cape, South Africa, provides guidance on measuring the health systems drivers, which are key to understanding the enabling factors, social dynamics and rights that underpin coverage and equity of women’s, children’s, and adolescents’ health. Health policy and systems research (HPSR) is an emerging field requiring different epistemologies, research methodologies and methods.
The Data & Analysis Center for Health Policy and Systems focuses on the following activities within the Countdown to 2030:
- Working with country partners to draw from the WHO RMNCAH policy database.
- Revisiting existing Countdown to 2030 health systems tools and adapt them to country team efforts to document the drivers of change in their contexts.
- Supporting country teams in qualitative approaches to understanding and measuring of health policy and systems.
The team uses existing health policy and systems research approaches that are primarily qualitative in nature and work in partnership with country investigators to support the overall analytical objectives of the DACs. This webinar provides an overview of health policy analysis methods and frameworks.
Key indicators related to health policy and systems are available in Countdown country profiles.
Background Resources and Materials
This document provides guidance on the defining features of HPSR and the critical steps in conducting research in this field. The audience is researchers and research users, teachers and students, particularly those working in low- and middle-income countries (LMICs). It provides guidance on the defining features of HPSR and the critical steps in conducting research in this field. It showcases the diverse range of research strategies and methods encompassed by HPSR, and it provides examples of good quality and innovative HPSR papers.
This document illuminates the range of health policy analysis studies that have been conducted in LMICs, highlights relevant theory, and points to new directions for such work. The primary objective of the reader is to encourage and deepen health policy analysis work in LMICs. It includes methodological and analytical pointers and considers how to use health policy analysis prospectively to support health policy change.
The Global Reproductive, Maternal, Newborn, Child and Adolescent Health Policy Survey tracks country progress in adopting WHO recommendations in national policies, strategies, laws, guidelines, reports that are relevant to the areas of sexual and reproductive health, maternal and newborn health, child health, adolescent health, gender-based violence and cross-cutting issues. The results of the fifth round of RMNCAH Policy Survey, conducted in 2018-2019, are available on the Maternal, Newborn, Child and Adolescent Health and Ageing data portal. The results of this global survey should serve as a benchmark for countries and help focus national efforts to implement strong, evidence-informed, equity-focused policies at the country level that span the continuum of care in SRMNCAH.
This document aims to promote greater understanding of the varied health policy and systems research approaches that can be applied to human resources for health (HRH). It provides resources that can be used for teaching and capacity development on HRH for researchers and practitioners alike. Key literature and teaching materials are provided.
Countdown to 2030 produced three brief documents to summarize these topics: health policy analysis, health systems analysis, and contextual factors.
Tools for Analysis and Communication
The Countdown to 2030 Policy and Program Timeline Tool is one approach to document changes in a country’s Reproductive, Maternal, Newborn and Child Health (RMNCH) policy, programmes, and implementation over time in an effort to see how these changes have contributed to women’s, children’s and adolescents’ health. The Countdown to 2030 Policy and Program Timeline Tool has been updated from the original Countdown to 2015 tools. The general aim of the tool is to understand through a standardised process, what health policy and systems factors have contributed to change (or the lack thereof) in RMNCAH in countries working with the Countdown to 2030 collective.
Access the program policy timeeline tool protocol
Access a template of the updated tool
The Health Policy Tracer Indicators Dashboard provides a systematic overview of the policy tracer indicators across the RMNCH continuum of care for a country by examining changes in these indicators from 1990 to present. The tool assesses and describes which RMNCH interventions have been translated into national-level policies (i.e. policy formulation component of the heuristic), and its visual output uses a “traffic light” colour coding system to illustrate if a policy has been fully (green) or partially (yellow) adopted, or does not exist (red). To access the information, go to the WHO MNCAH Policy data portal and click on "indicators" to access information.
This article provides context for the tool with detailed steps to guide implementation.
The Health System Implementation Readiness Barometer aims to identify good and bad performing districts or regions in order to understand why there is subnational variation in implementation of RMNCH interventions, with a focus on service availability and service readiness. The tool uses tracer indicators measuring the WHO health system building blocks — health financing, workforce, commodities, and facilities — overlaid with a heat map of health outcomes in a country showing subnational variation in RMNCH outcomes.
This article provides context for the tool with detailed steps to guide implementation.
The Accountability Measurement Tool aims to facilitate measurement of accountability processes or specific interventions by implementers. Presented in a paper by Martin Hilber and colleagues (2020), it aims to allow those who engage in RMNCAH accountability mechanisms or service delivery to conduct a self-reflection exercise to assess the potential efficacy of their efforts. By working through the tool, stakeholders can assess the results they contribute to, how and why their actions are working to increase accountability towards health-related outcomes or sustainability of an intervention, as well as what may need strengthening to show better results.
The "Most Significant Change" approach is a participatory method of collecting and analyzing stories from the field, which focuses on monitoring intermediate outcomes and impact. It provides a simple means of making sense of a large amount of complex information and is best suited to large-scale, open-ended projects, which would otherwise be difficult to monitor easily using traditional methods.
The process involves the collection of stories of change from a wide range of people in the communities where a specific project was implemented, followed by the systematic selection and prioritization of the most significant stories by designated stakeholders and staff based on criteria they determine for selection. Through the criteria setting and story selection, Most Significant Change allows stakeholders to input their values and subjective attitudes towards what constitutes significant change in a program. This methodology then “delivers a rich picture of what is happening, rather than an overly simplified picture where organizational, social and economic developments are reduced to a single number” (Davies & Dart, 2005).
The following publications are key articles by the Countdown to 2030 Drivers group or the previous Countdown to 2015 Health Policy and Systems group.
George A, LeFevre AE, Jacobs T, et al. Lenses and levels: the why, what and how of measuring health system drivers of women’s, children’s and adolescents’ health with a governance focus. BMJ Glob Health 2019;4:i143–i153. doi:10.1136/ bmjgh-2018-001316
George A, McConville F, deVries S, Nigenda G, Sarfraz S, McIsaac M. 2020. Violence against women health workers: The tip of the iceberg of gender power relations in global health. BMJ. 371 doi: https://doi.org/10.1136/bmj.m3546
George A, Amin A, Lopes Marques C, Ravindran S. 2020. Structural drivers of gender inequality: What are they and why do they matter for adolescent girl’s sexual and reproductive health. BMJ. 368 doi: https://doi.org/10.1136/bmj.l6985
Jennings L, George AS, Jacobs T, Blanchet K, Singh NS. 2019. A forgotten group during humanitarian crises: A systematic review on adolescent sexual and reproductive health interventions in humanitarian settings. Conflict and Health, 13(1), 57. https://doi.org/10.1186/s13031-019-0240-y
Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George AS. 2019. Implementation of maternal and perinatal death reviews: a scoping review protocol. BMJ Open. 9:e031328.
LeFevre AE, Shah N, Bashingwa JJH, George AS, Mohan D. 2020. Does women’s mobile phone ownership matter for health? Evidence from 15 countries. BMJ Global Health;5:e002524. doi:10.1136/ bmjgh-2020-002524
Mohan D, Bashingwa JJH, Tiffin N, Dhar D, Mulder N, George A, LeFevre AE. 2020. Does having a phone matter for women’s health? Linking phone access among women to careseeking in India: An exploratory analysis of the National Family Health Survey. Plos One. https://doi.org/10.1371/journal.pone.0236078
Singh NS, Huicho L, Afnan-Holmes H, John T, Moran AC, Colbourn T, Grundy C, Matthews Z, Maliqi B, Mathai M, Daelmans B, Requejo J, Lawn JE; Countdown to 2015 Health Systems and Policies Technical Working Group. Countdown to 2015 country case studies: systematic tools to address the "black box" of health systems and policy assessment. BMC Public Health. 2016 Sep 12;16 Suppl 2(Suppl 2):790. doi: 10.1186/s12889-016-3402-5.
The following publications serve as helpful examples on topics relating to health policy and systems, though they were not written by the Countdown consortium.
Victora CG, Schellenberg JA, Huicho L, et al. Context matters: interpreting impact findings in child survival evaluations. Health Policy Plan. 2005;20 Suppl 1:i18-i31. doi:10.1093/heapol/czi050
George, A., Scott, K., Garimella, S., Mondal, S., Ved, R., & Sheikh, K. (2015). Anchoring contextual analysis in health policy and systems research: A narrative review of contextual factors influencing health committees in low and middle income countries. Social science & medicine, 133, 159-167. doi:10.1016/j.socscimed.2015.03.049
Ramani S, Sivakami M, Gilson L. How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India. BMJ Glob Health. 2019 Jul 4;3(Suppl 3):e001381. doi: 10.1136/bmjgh-2018-001381. eCollection 2018.
Sabot K, Marchant T, Spicer N, Berhanu D, Gautham M, Umar N, Schellenberg J. Contextual factors in maternal and newborn health evaluation: a protocol applied in Nigeria, India and Ethiopia. Emerg Themes Epidemiol. 2018 Feb 6;15:2. doi: 10.1186/s12982-018-0071-0. eCollection 2018.
Shiffman J, Garcés del Valle AL. Political history and disparities in safe motherhood between Guatemala and Honduras. Population and Development Review 2006; 32(1): 53-80.
Buse K, Mays N, Walt G. Making Health Policy. London: London School of Hygiene and Tropical Medicine. 2012.
Gilson, L, Orgill, M, Shroff, ZC. A health policy analysis reader: The politics of policy change in low- and middle-income countries. Geneva: World Health Organization. 2018 https://www.who.int/alliance-hpsr/resources/publications/hpa-reader/en/
Gilson, L. Qualitative research synthesis for health policy analysis: what does it entail and what does it offer? Health Policy and Planning. 2014. 29(Suppl 3). https://academic.oup.com/heapol/issue/29/suppl_3 Leichter HM. A comparative approach to policy analysis: health care policy in four nations. Cambridge: Cambridge University Press, 1979
Adam T, de Savigny D. Systems thinking for health systems strengthening in LMICs: seizing the opportunity. 2012; 27 (Suppl 4). https://academic.oup.com/heapol/issue/27/suppl_4 Leslie HH, Hirschhorn LR, Marchant T, Doubova SV, Gureje O, Kruk ME. Health systems thinking: A new generation of research to improve healthcare quality. PLoS Med. 2018 Oct 30;15(10):e1002682. doi: 10.1371/journal.pmed.1002682. eCollection 2018 Oct.
Van Olmen J, Criel B, Bhojani U, et al. The health system dynamics framework: the introduction of an analytical model for health system analysis and its application to two case-studies. Health Culture and Society 2012; 2(1): 1-21.
Witter S, Palmer N, Balabanova D, et al. Health system strengthening—Reflections on its meaning, assessment, and our state of knowledge. The International Journal of Health Planning and Management 2019; 3(4). https://doi.org/10.1002/hpm.2882
Baker U, Peterson S, Marchant T, Mbaruku G, Temu S, Manzi F, Hanson C. Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania. Bull World Health Organ. 2015 Jun 1;93(6):380-9. doi: 10.2471/BLT.14.141879. Epub 2015 Apr 22.
Bergh AM, Pattinson RC. Development of a conceptual tool for the implementation of kangaroo mother care. Acta Paediatr 2003: 92(6), 709-714.
Martin Hilber A, Doherty P, Nove A, et al. The development of a new accountability measurement framework and tool for global health initiatives, Health Policy and Planning. 2020 https://doi.org/10.1093/heapol/czz170
Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci 2015;10:53. doi: 10.1186/s13012-015-0242-0
Karen Zamboni, Joanna Schellenberg, Claudia Hanson, Ana Pilar Betran, Alexandre Dumont, Assessing scalability of an intervention: why, how and who?, Health Policy and Planning, Volume 34, Issue 7, September 2019, Pages 544–552, https://doi.org/10.1093/heapol/czz068
Theory of change
Makowiecka K, Marchant T, Betemariam W, Chaturvedi A, Jana L, Liman A, Mathewos B, Muhammad FB, Semrau K, Wunnava SS, Sibley LM, Berhanu D,Gautham M, Umar N, Spicer N, Schellenberg J. Characterising innovations in maternal and newborn health based on a common theory of change: lessons from developing and applying a characterisation framework in Nigeria, Ethiopia and India. BMJ Glob Health. 2019 Jul 18;4(4):e001405. doi: 10.1136/bmjgh-2019-001405. eCollection 2019.
Paina L, Wilkinson A, Tetui M, Ekirapa-Kiracho E, Barman D, Ahmed T, Mahmood SS, Bloom G, Knezovich J, George A, Bennett S. Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda. Health Res Policy Syst. 2017 Dec 28;15(Suppl 2):109. doi: 10.1186/s12961-017-0272-y.